8 tips to simplify patient assessment

Simplifying the patient assessment process for every patient can reduce variability, lower your stress and improve patient care

Live simple. Real simple. Simplify your life. Get simple.  

In a noisy world with constant distractions, opportunities and clutter, there are countless slogans, signs, memes and TikTok videos that encourage us to simplify. There is even a “National simplify your life week” every August. I will let the influencers du jour tell you how to simplify your finances, clutter or kitchen utensils, and stick to eight tips to simplify your patient assessment.  

1. One person talks to the patient 

Reduce distractions during the patient assessment by politely asking for the television to be turned off or turned down, and for bystanders to step back and give you more space.
Reduce distractions during the patient assessment by politely asking for the television to be turned off or turned down, and for bystanders to step back and give you more space. (Photo/Idaho State University)

When more than one EMS provider is asking the patient questions about their pain or medical history, the patient is likely to get confused or miss questions and important information. Instead, let just one person ask the patient questions. That same person can also explain assessment and treatment procedures.  

2. Use a process for the primary and secondary assessment 

Patient assessment doesn’t need to be linear, but it also shouldn’t be a meandering conversation. Consistently following a process or set of steps ensures you gather important information for every patient in a timely manner.  

3. Rule out problems 

Initially, cast a wide net and consider a wide array of problems and causes for the patient. As you gather information with the physical exam and SAMPLE history, rule things out. For example, if a patient is confused but has a normal blood sugar, rule out hyper- and hypoglycemia while continuing to consider other causes. Letting go of some possibilities will help narrow the investigation to the actual cause of the patient’s illness or injury.  

4. Reduce distractions 

A patient’s living room, bedroom or kitchen can be filled with distractions. It’s within your rights to politely ask for the television to be turned off or turned down. Kindly ask bystanders to step back to give you more space to assess and treat their loved one. If you have enough personnel, assign someone to manage the bystanders, communicate with them about the assessments and treatments being performed, and to gather patient information that might help your assessment. This lets you stay focused on the patient.  

5. Document as you go 

You’ve probably been on a scene where the patient was asked three times if they have any allergies or a provider needed to ask about medications more than once. Document what you learn about the patient’s history as you go in a notebook or piece of scrap paper. If you can easily make notes and access them throughout the call, begin filling out the ePCR.   

6. Give specific instructions 

When you need another provider, the patient or a bystander to do something, be as specific as possible in your instructions. For example, don’t just tell the patient to “hold on” as you begin to move them down the stairs in a stair chair. Be specific, “cross your arms, hold those shoulder straps and keep your arms crossed as we move you down the stairs.”  

7. Use job aids 

Checklists reduce variability and the risk of error. They also make sure important assessments are made, guide treatment decisions and make sure critical interventions are performed. Job aids in the form of checklists, smartphone applications and machine instructions simplify patient assessment. Use them.  

8. Back to basics 

For a critical patient in a high-stress environment, remind yourself of the basics of perfusion. The mantra, “air goes in and and out – blood goes round and round” can both calm you down and refocus you on finding and fixing life threats.  

What are your tips for students and new EMTs to simplify the patient assessment process? Do you have any specific suggestions to simplify patient assessment for experienced paramedics? Share them in the comments.  

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